The Annual Vendor Briefing occurs shortly after the publishing of ORYX Quality Performance Measure requirements. Below is a summary.

For those who are not familiar with The Joint Commission's (TJC) ORYX Program, it is a quality initiative program that embeds performance and outcome into its accreditation and certification processes. This allows Joint Commission accredited and certified organizations to be a part of ORYX quality improvement efforts.

Large hospitals participating in the ORYX quality program are required to submit quality measurement data with a ORYX vendor. Large hospitals defined by The Joint Commissions have an average daily census (ADC) of greater than 10 inpatients. ORYX chart-abstracted data is publicly reported on The Joint Commission website at Quality Check, www.qualitycheck.org.

TJC schedules their vendor briefing shortly after they publish their annual ORYX quality performance measures requirements. TJC and CMS hold an annual vendor briefing to review with ORYX vendors updates to quality measurement program for the following submission year. Members from the CMS quality reporting team attend the vendor briefing to review CMS quality programs as well. It's great The Joint Commission includes CMS at the vendor briefings.

Acmeware is an listed ORXY eCQM vendor. I've been attending the annual vendor briefing for the past two years and the most noticeable change I've seen is the increase in ORYX eCQM vendors. In addition, the topics and content over the past couple years has shifted from chart-abstraction to eCQM reporting.

CMS has come out many times in the past with CQM guidance indicating chart-abstracted reporting methods will be replaced with Electronic Health Record reporting using Electronic Clinical Quality Measures. CMS indicted they are not putting new money into Core Measure reporting. All new work is going to eCQM development for reporting outcomes and quality. CMS is pushing for EHRs at hospitals and this is direction of eCQMs. Currently, electronic reporting via EHR is required for IQR. In the near future it will become more and more difficult for hospitals and providers to participate in IQR, OQR and PQRS without an EHR.

2017 Reporting and Submission Requirements

On September 7, 2016, The Joint Commission finalized the 2017 ORYX Performance Measurement requirements continuing their commitment to remain closely aligned with the CMS Hospital Inpatient Quality Reporting (IQR) Program. Hospitals will be required to report on 6 of 13 available eCQMs applicable to the services provided and patient populations served by the hospital. In addition, hospitals will need to report 4 quarters of data for calendar year (CY) 2017 by the annual submission date (3/15/2018).

Significant Impact

In 2015, TJC provided hospitals with greater flexibility in meeting their 2015 ORYX performance measure requirements and to more closely align its quality reporting requirement with CMS. Hospitals had option to submit eCQMs, abstracted quality measures or a combination. In 2017, TJC reneged on the commitment to supporting all eCQMS and will now require hospitals to submit both Chart-Abstracted measures and eCQMs. This is a step backwards but we can discuss this at another time.

This year CMS and TJC presented great presentations on how their vision and strategy come together with clinical quality measurement and reporting. Some of the key points from the presentations.

The first time in the history of the program CMS has explicit goals for alternative payment models and value-based payments are set for Medicare. CMS as set measurable goals and a timeline to move Medicare toward paying providers based on quality, rather than the quality of care. CMS has adopted a framework that categorized payments to providers.

This program aims to support better and more efficient care for beneficiaries undergoing lower extremity joint replacements (LEJR). The model holds participant hospitals financially accountable for the quality and cost while incentivizing coordination of care among hospitals, physicians and post-acute care providers.

Joint Commission eCQMs

New eCQMs coming soon

De Novo eCQMs

Five (5) Patient Blood Management eCQMs

Four (4) Total Hip/Total Knee Replacement eCQMs

Re-Specified and Legacy

VTE-1 though VTE-6

STK-2 through STK-10

PC-01, PC-02, PC-05

CAC3

TOB-1 through TOB-3

Safe Use of Opioids

Electronic quality measure (eCQM) in development to address concerns associated with overlapping or concurrent prescribing of opioids .

Proposed Policy Changes

Time frames for preview period: publicly display data on Hospital Compare website, or other CMS website, as soon as possible after measure data have been submitted to CMS